Background and introduction 121 Preoperative investigation 123 Patient preparation 123 Exposure 123 Vascular dissection 126 Dissection of the mesentery and division of inferior mesenteric vein 129 Mobilisation 131 Anastomosis 141 Conclusions 143 Take-home message 144 References 144

Learning Objectives

Understand that laparoscopic total mesorectal excision (TME) is a challenging technique, with increased difficulty due to the male pelvis, bulky tumours, bony confines of anatomy, preoperative chemoradiation, and so on.

Recognise solutions for challenges encountered during TME by understanding the concept of standardisation of the operative technique, which is applicable to all patients undergoing laparoscopic TME surgery.

Become familar with the concept of the modular approach, as the operation is divided into simple steps for task completion and teaching and training. This system of teaching provides a valuable tool for better feedback to trainees with a focus on each of the steps.

Be aware of specific intra-operative difficulties that can be encountered during the surgery, and understand suggested solutions.